- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,398.83
| Facility | | $1,096.48 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,445.44 / $2,454.71
| Professional | | $1,122.02 | $1,445.44 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $11,220.18 / $15,488.17
| Facility | | $9,549.93 | $11,220.18 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $2,041.74
| Professional | | $1,202.26 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Professional | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,659.59 / $5,248.07
| Facility | | $660.69 | $1,659.59 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $1,949.84
| Professional | | $891.25 | $1,230.27 | $1,949.84 |